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Patient Partners for Equity Organization Profile Form
Name of Organization
*
Website Address
*
Mailing Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Name of Primary Organizational contact
*
First
Last
Email of Primary Organizational contact
*
Phone number of Primary Organizational contact
*
Will this contact be the POC for the Patient Partner for Equity Program?
*
Yes
No
Name of Secondary Organizational contact
First
Last
Email of Secondary Organizational contact
Phone number of Secondary Organizational contact
Will this contact be the POC for the Patient Partner for Equity Program?
Yes
No
Please provide the Organization’s Mission Statement
*
Please upload the logo for use on the PAF websites
(500px maximum, .jpg format preferred .png also acceptable)
What is your geographic focus?
*
Please Specify Below
National (United States)
Regional United States
State or local
State or country if applicable
Outside of the United States
Global
Geographic Details
Is your organization designated as a nonprofit organization?
*
Please provide details below
Yes
No
Please provide details if you are not a nonprofit organization
*
Does your organization focus mainly on a particular disease or condition?
*
Please select one that best describes your organization and provide details below.
We focus on multiple diseases or conditions, including cancer
We focus on one or more diseases or conditions but not cancer
We focus on all types of cancers
We focus on a few or certain types of cancers, diseases or conditions
We focus on one cancer, disease or condition
We do not focus on any specific diseases or conditions
Please provide details about your organization's disease area(s) of focus.
*
What types of diseases does your organization focus on?
*
Please select all that apply. You must select at least one
All Cancer
Specific type(s) of cancer
ALS
All Chronic Conditions
AIDS, HIV or prevention
Cystic Fibrosis
Heart or Heart Valve Conditions
Hepatitis
Migraine
Pulmonary Fibrosis
Rare Diseases
Sickle Cell Disease
Spinal Muscular Atrophy
Other Disease(s) or Condition(s)(please specify)
Disease or Condition Area of Focus Details
*
Which of the following topics do you consider a major focus for your organization as it relates to health, cancer or other chronic and serious diseases or conditions?
*
Please select all that apply.
Access to care
Advocacy/Public Policy
Behavioral health or wellness
Clinical trials
Disease awareness
Family or caregiver issues
Fertility preservation or family planning
Financial issues
Genetics
Health Disparities
Post-treatment/survivorship
Screening or prevention
Treatment
Other
Other (please specify}
Does your organization provide direct support to patients, families and/or caregivers through a dedicated patient hotline/call center or peer to peer programs?
*
Yes
No
Does your organization have a formalized health equity and inclusion (HEI) or diversity, inclusion and equity (DEI) program?
*
Yes
No, but we have a HEI or DEI priority or imperative as an organization
No
Does your organization focus on one particular group or population?
Please provide any details on the population you focus on most.
Which of the following describe reasons why you might partner with an organization?
*
Please select all that apply.
To expand our program or initiative reach to new people
To share our content or expertise with other organizations
To increase our organization's visibility or exposure
To gain insights or expertise from other organizations
To fulfill a partnership requirement by a granting agency
To understand or incorporate the voice or experience of people that our organization does not reach
To receive help with our efforts on a project
To help address barriers, disparities or inequities
To raise awareness of our constituency's needs to people outside of our community
To reach consensus or develop guidelines across organizations
Other
Which of the following are important components of your organization's programs or initiatives?
*
Please select all that apply.
Public policy
Awareness
Education
Peer or emotional support
Guideline or consensus development
Conducting research
Training consumers to participate in the research process
Providing grants for research
Career development
Providing financial support to patients
Providing other physical support to patients (e.g., transportation, child care services, delivering meals, etc.)
Providing navigation support to patients (e.g., directing them to resources, information or services.)
Other
Overall, about how many people did your organization reach in the last year?
100,000 or more
25,000 - 99,000
10,000 - 24,999
1,000 - 9,999
500 - 999
100 - 499
Less than 100
Uncertain
By completing this organizational profile, you are confirming the following:
Your organization’s desire to partner with PAF as a Patient Partner for Equity
PAF has permission to utilize your logo and mission statement on our websites,
www.patientadvocate.org
and
www.copays.org
, on the Patient Partner for Equity pages.
PAF has permission to add the primary, secondary and program contacts provided in this profile form to the Patient Partner for Equity listserv for the purposes of receiving PAF and NPAF communications relative to the Patient Partner for Equity and other general organizational communications. Emails will be sent from PAF's email management system, MailChimp.
I understand and agree to these conditions.
*
Yes
No
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Home
Health Equity Funds
Patient Partners for Equity
Get to Know Us
Board of Directors
Staff Leadership
Reports & Financials
Patient Impact
Frequently Asked Questions
Media Center
Patient Resource Center
Contact Us
Patients & Family
Providers
Pharmacies
Donors
Commitment to Compliance
Apply
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